Interhospital Transfer for Acute MI Associated With Disruptions in Aftercare, More Readmissions
Patients with acute MI who require transfer to
PCI-capable hospitals are less likely to receive timely postdischarge follow-up
compared with patients who are directly admitted to PCI-capable hospitals. Results
of a new study also show that transferred patients have higher rates of all-cause
and cardiovascular readmission at 30 days, although both groups have similar
rates of mortality.
“This suggests that there may be room for improvement in transitioning these patients back to the community,” lead author Amit N. Vora, MD, MPH, of Duke University Medical Center (Durham, NC), told TCTMD in an email.
For their study, published online January 26, 2016, in Circulation: Cardiovascular Quality and Outcomes, Vora and colleagues utilized Medicare claims data to examine postdischarge outcomes in 39,136 acute MI patients treated from 2007 through 2010 at 451 US hospitals in the ACTION Registry-Get With the Guidelines. Of these, 36% required an interhospital transfer, which involved a median travel distance of 43 miles. All patients underwent revascularization.
Transferred patients were slightly younger than direct-arrival patients (median age, 73 vs 74) but were less likely to have a history of MI, heart failure, or revascularization prior to treatment.
Disparity in Follow-Up Care
At 30 days after discharge, transferred patients were less likely than direct-arrival patients to have been seen for an outpatient follow-up appointment and had higher adjusted risks of all-cause and cardiovascular readmission. Risk-adjusted mortality, however, was similar (table), as were in-hospital complications including cardiogenic shock, heart failure, stroke, and major bleeding.
.JPG "Acute MI Patients")
Even for those transferred patients who received follow-up within 30 days, the median time to follow-up was longer than in the direct-arrival group (16 days vs 13 days; P < .001).
At time of discharge, patients in both groups had high and similar rates of guideline-recommended secondary prevention medications (aspirin, P2Y12 receptor inhibitors, beta-blockers, and statins). Smoking cessation counseling also was equally apt to occur in both groups, but transferred patients were more likely to receive diet modification counseling and cardiac rehab referrals.
By 1 year, there continued to be no difference in risk-adjusted all-cause mortality rates between the transferred and direct-arrival patients (8.0% vs 8.5%; P = .24). In a secondary analysis, longer transfer distances did not appear to impact 30-day follow-up, readmission, or mortality.
Performance Measure Implications
“We were somewhat reassured that overall mortality was similar between the 2 groups, though this may have to do more with their initial presentation and care than the differences in follow-up after discharge,” Vora said. He added that being aware that transferred patients have lower follow-up rates is important, although the study cannot address why this is the case.
The lower likelihood of aftercare “may have to do with additional logistic barriers as they transition back after discharge. I would imagine that most hospitals make follow-up appointments prior to discharge when possible, though these appointments may be close to the hospital and not the patient’s home health care environment,” Vora observed.
According to Vora, the findings are of particular importance in an environment where readmissions following discharge are tracked carefully as a performance measure and may be tied to reimbursement. Identifying patients at higher risk for readmission and creating tailored plans for postdischarge care, he added, may be important for improving care for these patients.
Source:
Vora AN, Peterson ED, Hellkamp AS, et al. Care transitions after acute myocardial
infarction for transferred-in versus direct-arrival patients. Circ Cardiovasc
Qual Outcomes. 2016;Epub ahead of print.
Disclosures:
- The study was supported by a grant from the Agency for Healthcare Research and Quality.
- Vora reports no relevant conflicts of interest.
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L.A. McKeown is a Senior Medical Journalist for TCTMD, the Section Editor of CV Team Forum, and Senior Medical…
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